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  1. Clerk’s Grandrounds Go, K, Go, MR, Go, MF, Go, MH, Go, RM

  2. General Data HB3 years old/femaleSta. Cruz, ManilaBirthdate: Feb. 8, 2007Admitted: January 1, 2011Informant: ParentsReliability: GoodCC: Fever

  3. Chief Complaint • Difficulty of breathing

  4. History of Present Illness

  5. Review of Systems • General: no weight loss/gain (+) anorexia, (+) weakness • Cutaneous: no rashes, no abnormal pigmentation, no pruritus • HEENT: no lacrimation, (+) naso-aural discharge, no epistaxis, no salivation

  6. History of Present Illness • Cardiovascular: no cyanosis • Respiratory: see HPI • Gastrointestinal: see HPI • Genitourinary: see HPI

  7. Growth and development: • At par withage • Feedinginjury • Solidfoodintroduced: 6 months • First foodintroduced: Cerelac • Number of feeding per day: 3x of smallfeedings/ day • Pastmedicalhistory: • No allergicrhinitis, no atopicdermatitis, previoushospitalizations and surgeries • Familyhistory: (+) asthma - father (-) allergicrhinitis, foodallergy, atopicdermatitis, congenital anomalies • Immunizationhistory: • Completed

  8. Social/Environmental history • Patient’s aunt is the primary caregiver • patient together with her parents and aunt live in a bungalow type house with an average monthly income of P20,000 • House has adequate space and ventilation • Patient’s drinking water is from NAWASA • Garbage is segregated and collected daily • No smokers in the household and no factories nearby

  9. Physical Examination • General: Lethargic, in cardiorespiratory distress, carried, ill-looking, poorly nourished and hydrated • Vital Signs: BP: 80/50 PR=140 bpm RR=56 T=36.9 O2 sat 75% • Anthropometric data: weight: 11kg (weight for age: below 0: normal), Height: 94 cm (length for age: 0: normal), (weight for height: below -2: wasted), BMI: 12 (below -3: severely wasted) • Warm moist skin, (-) active dermatoses, (-) hematoma

  10. Physical Examination • HEENT: Normocephalic, No scalp lesions, (-) alopecia, pale palpebral conjunctivae, anicteric sclera, non-hyperemic, pupils 1-2 mm ERTL, no tragal tenderness, non-hyperemic EAC, (+) impacted cerumen on the left, midline nasal septum, (+) nasal discharge, (+) alar flaring, dry buccal mucosa, dry lips, (-) oral ulcers, tonsils not enlarged, NHPPW, supple neck, thyroid not enlarged, no cervical lymphadenopathies,(+) bilaterally symmetrical submandibular swelling

  11. Physical Examination • Lungs/ Chest: • Symmetrical labored chest expansion • (+) suprasternal retractions, (+) intercostalretractions • (+) 14x10 cm swelling non-erythematous warmth at posterior thorax 5th – 10th intercostals space, (+) crepitations over anterior and posterior thoraces, (+) hyperresonance • (+) wheezes with fair to tight air entry, (+) rhonchi, (+) fine crackles on both bases

  12. Physical Examination • Cardiovascular: Adynamicprecordium, AB 5th LICS MCL, (-) heaves, thrills and lift, S1>S2 at the apex, S2>S1 at the base, (-) murmurs • Abdomen: Flat abdomen, normoactive bowel sounds, (-) direct tenderness in epigastric area, no masses, no rebound tenderness • GUT: no CVA tenderness, grossly female, Majora covers minora • Extremities: Pulses full and equal on all extremities, no cyanosis, (+) crepitus subcutaneous emphysema overboth arms 14x16 cm of non-hyperemic, non-tender, (-) rubor swelling mass

  13. Neurological Exam • Conscious, coherent oriented to person, time and place, GCS 15 • No anosmia, Pupils Left 2-3 mm isocoric ERTL, (+) corneal reflex, (+) ROR, clear disc margins, no visual field cuts, EOM full and equal, V1V2V3 intact, (-) ptosis, (-) shallow right nasolabial fold, can smile, can raise eye brows, can puff cheeks, (-) lateralization on Weber, AC>BC on Rinne’s AU, (+) gag reflex, can shrug shoulders, turns head side to side against resistance, tongue midline on protrusion, uvula midline on phonation • Motor: MMT 5/5 on all extremities, no fasciculation, spasticity, flaccidity • Sensory: (-) sensory deficiency • DTR’s: +2 on all extremities • (-) Babinski, right, (-) nuchal rigidity, (-) kernig’s

  14. Salient Features • 3 year old/female • Difficulty of breathing • Known case of asthma maintained on salbutamol • Hypotensive, tachycardic, tachypneic, hypoxemic, afebrile • Lethargic, in cardiorespiratory distress, poorly nourished and hydrated • - (+) suprasternal retraction, (+) intercostal retractions, (+) wheezes, (+) ronchi • (+) 14x10 cm swelling non-erythematous warmth at posterior thorax 5th – 10th intercostals space • (+) crepitus subcutaneous emphysema at both arms 14x16 cm of non-hyperemic

  15. Assessment • Bronchial Asthma, in Moderate Acute Exacerbation • Secondary Spontaneous Pneumothorax, probably due to Bronchial Asthma • Pneumonia • Subcutaneous Emphysema

  16. Day 1 • Hooked to O2 per mask • IVF D5 0.3 NaCl 500cc to run at 11-12gtts/min • CBC: Increased WBC count • ABG • Portable CXR: Extensive subcutaneous emphysema of the chest and neck area and probable pneumothorax, left • Medications • Methylprednisolone 11mg/SIVP Q6 • Ampisulbactam 300mg/SIVP Q6 • Salbutamol 2.5mg/nebule 1 nebule every hour • Referred to PediaPulmo and PediaAllergo

  17. Day 2 • (+) dry lips • Increased IVF to 16-17gtts/min • Initiated liquid, then soft diet • Ranitidine 10mg/SIVP

  18. Day 3 • (+) epigastric pain relieved by ranitidine • (+) 4 episodes post-tussive bilious vomiting • Aminophylline 2.2ml in 20ml IVF to run for 30 mins then maintained at 2.2ml + 97.8 IVF to run at 20ml/hr • (-) tachycardia, headache, seizure, GI upset • Mucosolvan 10 drops added to 20 drops ambroxol and salbutamolnebule • Further increase bronchodilation

  19. Day 4 • Follow up CXR • Remarkable improvement of subcutaneous emphysema • Adequate expansion of the left lung • Aminophylline drip and IV methylprednisolone discontinued • Doxophylline 100mg/5ml (10mg/kg/day) 2.5ml BID • Methylprednisolone 8mg/tab 1 tab Q8

  20. Day 5 • Oral methylprednisolone discontinued

  21. Day 7 • (+) congested turbinates • (+) vomiting • (+) abdominal pain • Ranitidine discontinued • Lansoprazole (Prevacid) 15mg/tab ½ tab OD

  22. Day 8 • Discharged stable and improved

  23. Final Diagnosis • Bronchial asthma, in moderate acute exacerbation • Secondary spontaneous pneumothorax secondary to bronchial asthma • Pneumonia • Subcutaneous emphysema, resolved

  24. Case Discussion

  25. Journal